PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)

Transcription

1 REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please list medication allergies: Are you allergic to iodine/iv contrast dye? PERTINENT HISTORY Medical History (please list past and current conditions): Medical Problems Surgeries Do you have any of the specific medical conditions listed below: Inflammatory Bowel Disease Crohn s Disease Ulcerative Colitis Lupus Scleroderma Claustrophobia UCLA Form # Rev. (01/12) Page 1 of 5

2 Have you ever had: Previous Radiotherapy Previous Chemotherapy GYNECOLOGICAL (female patients only): Number of pregnancies: Have you ever taken oral contraceptives or hormone replacement medication? Number of children: If yes, what type: Age at first live birth: Age periods first started: Date of last Pap Smear: Age at menopause (if Date of last Mammogram: postmenopausal): Menopause Status: Premenopausal Postmenopausal Don t know FAMILY HISTORY Have any of your family members ever had cancer? If yes, please list relationship and type of cancer in your family member(s): SOCIAL HISTORY: Smoking Never smoked Smoke currently Smoked previously Alcohol Never drink alcohol Occasionally drink alcohol Frequently drink alcohol If you smoke currently or have smoked in the past: Number years smoked Number packs per day Number years quit If you drink alcohol currently or have done so in the past: Number days drink/week Number drinks/day Number years quit UCLA Form # Rev. (01/12) Page 2 of 5

3 Employement: Are you employed? If yes, what is your occupation: Support Systems: Do you live alone? Do you live with your spouse, significant other, family or friends? Do you live in your own house/appartment? Do you live in a nursing home? Do you live in an assisted living environment? Other comments: Transportation: Would transportation to UCLA for daily treatments be difficult for you? If Yes, please explain: System Review: Please check yes or no box to indicate if you have any of the following Immunology/Allergy Allergies to animals or plants Reactions (Runny Nose or itchy eyes) Cardiovascular Irregular heart beat (arrythmias) Chest Pain Difficulty walking two blocks (dyspnea) Swelling of hands, feet or ankles (edema) Shortness of breath while walking or lying down (orthopnea) Heart Murmur (palpitations) Genitourinary (Female) Burning or painful urination Frequent urination Blood in urine Incontinence Frequent night time urination Kidney / bladder stones Sexual difficulty Urgency with urination Urine color change Vaginal discharge/bleeding Vaginal spotting UCLA Form # Rev. (01/12) Page 3 of 5

PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your

Review Of Systems Y N P a condition you have now a condition you have NEVER had a condition you have had in the past Responses and Comments: 1. General Weight Weight 1 year ago Maximum weight When Height

NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)

St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have

Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of

Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer

USF Eye Institute and Ear, Nose and Throat Center Neuro-Opthamalogy Dear Neuro-ophthalmology Patients: The following information is to prepare you for your visit with Dr. Drucker. If you have had an MRI,

MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems

NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address

Name: Address: Home Phone: Cell Phone: Email Address: Date of Birth: Primary Care Physician: Why have you been referred for a Cardiovascular Genetics Appointment? Have you had a genetics evaluation? If

HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:

E/M LEVEL WORKSHEET STEP 1 : IDENTIFY THE CATEGORY AND SUBCATEGORY OF SERVICE Carefully read the documentation. Using the Table of Contents, identify the appropriate category/subcategory. Category Subcategory

PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration

PODIATRIC ASSOCIATES OF NW OHIO, INC. DATE PATIENT HISTORY PATIENT S LAST NAME FIRST NAME MIDDLE SOCIAL SECURITY NUMBER ADDRESS STREET APT. NO. CITY STATE ZIP DATE OF BIRTH AGE SEX MARITAL STATUS HOME/CELL

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.

GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:

Medical Intake Form Please complete all of the following as accurately as possible: Name Age Birthdate Sex Address City Zip Phone (H) (W) Occupation Full Time / Part Time Employer Education Level Married

Date New Patient Packet E-mail Address Social Security Number D.O.B Patient's Last Name Patient's First Name Middle Initial Age: Home Phone: Cell Phone: Work Phone: Address Male/Female: Single/Married/Divorced/Widowed

BACK & NECK QUESTIONNAIRE Please answer all questions completely. It is in your best interest and will assist your doctor with your care. Be sure to bring this form with you to your appointment. Patient

(Please fill out this form and bring it with you to your appointment.) Name Date Date of Birth Age Sex: M F Height: ft. in. Weight lbs Primary Physician Referring Physician (If Different) CURRENT PROBLEM

Evan Wolf, MD PhD Jacob Frank, OD PATIENT REGISTRATION Welcome to our office. In order to serve you properly, we will need the following information. (Please Print) Patient First Name Middle Initial Last

Breast Cancer Summary Breast cancers which are detected early are curable by local treatments. The initial surgery will give the most information about the cancer; such as size or whether the glands (or

(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last

Personal History Rheumatology Associates of North Jersey New Data Sheet To our new patients: Welcome to our practice. SS: - - Date: Last Name: First Name Date of Birth / / Age Address City State Zip Code

It is a pleasure to welcome you to Florida Digestive Specialists (Formerly Gastroenterology and Oncology Associates)! We strive to exceed your expectations and provide you with the best service possible.

Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects

Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken

PATIENT DEMOGRAPHICS: Last Name: First: MI: Address: City: State: Zip: Please check off the phone numbers you would like us to call regarding appointment conformations. Home: Cell: May we leave a message?

Presenting the SUTENT Patient Call Center. Please see patient Medication Guide and full prescribing information attached. We re here to support you. Dealing with cancer is a journey. Along the way, you